Original Article

The effect of face washing frequency on acne vulgaris patients

Rini Hastuti, Etty Farida Mustifah, Imroatul Ulya, Muhammad Risman, Prasetyadi Mawardi

Department of Dermatovenerology, Medical Faculty of Sebelas Maret University,

Dr. Moewardi General Hospital, Surakarta, Indonesia

Email: rinihastuti1402@gmail.com

Abstract
Background: Patients with acne often wash their faces twice a day, but there are not many studies
supporting this practice.
Methods: A single-blind randomized clinical trial was conducted in 38 subjects, divided into three groups
based on face washing frequency (once, twice, and thrice a day). All groups used the same cleanser. The
acne vulgaris severity and the number of lesions were assessed prior to study. After eight weeks, we re-
assessed the acne severity, the number of lesions, the adverse event and patient’s self-evaluation. SPSS 17
was used to analyze the face washing frequency and the number of acne lesions.
Results: Reduction in the average number of acne lesions was found in once and twice face washing
groups, while the thrice group had increased number of acne lesions. The frequency of face washing with the
number of lesions provided significant result in group 1, but it only reduced the number of comedones
(p value = 0.041).
Conclusion: Acne patients with only comedones lesions can be advised to wash their faces once a day.

Keywords: acne vulgaris, face washing, frequency

Background most literatures simply grade the severity of acne

Acne vulgaris (AV) is a chronic inflammatory
disease of the pilosebaceous follicles, that is
characterized by comedones, papules, pustules,
cysts, nodules, and occasionally scars.1 The
prevalence is high in adolescents and it mostly
affects the face in (99%) of patients and less
frequently the trunk, back (60%), chest (15%),
shoulders and buttocks. 2,3
The etiologic factors of acne are increased sebum
production, hypercornification of pilosebaceous
ducts, colonization of skin micro flora and
inflammation.4 Several factors known to be
implicated in AV include stress, menstrual period
facial hygiene, and foods, such as fatty food,
sweets and spices,5,6
Diagnosis of AV is established by physical
examination. The medical personnel need to
assess the severity of acne.7 Several rating scales
have been developed with the aim of trying to
grade the severity of the individual`s condition. No
method has yet gained universal acceptance and
as mild, moderate, and severe.8
The primary goals of acne therapy are to achieve
initial control, maintain therapy to prevent flares,
and prevent persistent or permanent sequelae
such as scarring. An important aspect of AV
management that is often forgotten by physicians
is to dispel any myths and misperceptions that the
patients may have about the cause of their AV.9 A
survey of patient’s perception of AV showed that
they thought that acne was caused by poor skin
hygiene.10
In order to prepare the skin to receive topical
medications and to improve drug absorption, the
regular using of mild cleanser is an important
component in effective acne management.
Routine cleansing not only increases the
antimicrobial activity, but it also decreases the risk
of infection, removes excess sebum, and prevents
hair follicular obstruction. 11,12
Patients with acne often mistakenly believe that
aggressive scrubbing of their skin with soap and
water several times a day can reduce the oiliness

J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 35

of their skin.13 The doctors usually give
recommendation to wash the face twice daily with
a mild cleanser, even though, there is not much
published literature to support this practice.14
This study was conducted to determine the effect
of face washing frequency on acne vulgaris, so
that we could provide the right education to the
patients about the optimal face washing frequency
to reduce the prevalence of acne.
Methods
This research is a single blind, randomized, and
clinical trial study, conducted during the period of
November 20, 2016 until January 15, 2017 at Al
Muayyad Boarding School Surakarta. A total of
sixty subjects were recorded to participate in the
beginning of the study. The inclusion criteria are
as followed: male, aged 12-18 years old, willing to
not use other cleansing products and acne
treatments during the study, classified into mild
and moderate acne criteria according to Global
Acne Grading System (GAGS), and willing to sign
an informed consent. The criteria of mild and
moderate acne were based on the GAGS scoring
system, in which its system can be assessed
quickly and easily (Figure 1 and Table 1).
Subsequently, subjects were divided into three
groups, each consisted of twenty subjects, in
which group 1, group 2 and group 3 washed the
face with a cleansing soap for once a day, twice a
day, and thrice a day, in orderly manner.
Prior to the study, an assessment of the degree of
acne severity by using GAGS and by counting the
Figure 1. Six Locations in Global Acne Grading System (GAGS) 15
J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40.
number of lesions including blackheads, papules,
pustules, and nodules was conducted. This
grading system considers six locations on the face
and chest/upper back (Figure 1), with a factor for
each location based roughly on surface area,
distribution, and density of pilosebaceous units.
Each location is graded separately on a 0 to 4
scale, with the most severe lesion on the location
determines the local score. The global score is a
summation of all local scores. (Table 1).15
All subjects were given the same cleanser. It is a
cleansing soap with no antiseptic nor anti-
bacterial content, namely Primaderma® Normal
Skin Face Wash with composition of aqua,
sodium laureate sulfate, cocamidopropyl betaine,
cocamide DEA, decyl glucoside, PEG-150
distearate, PEG-12 dimethicone, sodium PCA,
phenoxyethanol, tetrasodium EDTA,
methylparaben, citric acid, perfume, butylparaben,
ethylparaben and propylparaben. There was no
wash out period before the study began.
At the end of the study, at week 8, re-assessment
of the severity of acne, lesion count, side effects
(e.g. red, scaly, dry, stinging, hot, or itchy) and
patient’s self-evaluation with history taking by
asking the subjects if there was a change in the
number of acne lesions (improvement, no
improvement, or worsen).
Statistical analysis was performed to determine
the relationship between face washing frequency
and number of acne vulgaris lesions using SPSS
with T-test and Anova test (significance level p
<0,05).
36
Table 1. The Global Acne Grading System (GAGS) 15

Location Factor x Grading (0-4)* = Local Score

I. Forehead 2
II. Right Cheek 2
III. Left Cheek 2
IV. Nose 1
V. Chin 1
VI. Chest and upper trunk 3
*Grading: 0 = No lesion; 1 = Comedones; 2 = Papules; 3 = Pustules; 4 = Nodules
GAGS Score: 0 = Zero; 1-18 = Mild; 19-30 = Moderate; 31-38 = Severe; >39 = Very Severe

Results
Initially, sixty subjects were divided into three
groups and each group consisted of twenty
people. After 8 weeks, subjects who discontinued
research protocol were excluded from the study
(drop-out subjects), Meanwhile, the subjects who
did not follow the procedure properly were moved
to another suitable group. Thus, the number of
subjects for group 1 was nine people, group 2 was
nineteen people and group 3 was ten people
(Figure 2). The average age of subjects in group
1 was 16 years old, group 2 was 15.4 years old,
and group 3 was 13.9 years old
The degree of severity of subject’s acne based on
GAGS before and after the study is shown in
Table 2. After 8 weeks of study, group 1 and 2
had more subjects with mild acne severity and
decreased number of subjects with moderate
acne severity. While group 3 showed there was a
decrease in the number of subjects with mild acne
severity. On the other hand, there were more
subjects with moderate acne severity.
The average number of comedones, papules,
pustules, and nodules lesions before and after the
study is shown in Table 3. On group 1, there was
a significant reduction in the number of
comedones with p value = 0.041, meanwhile the
other groups did not give significant result.
Table 4 shows the results of the assessment of
adverse event, in which most subjects felt no
complaints. Table 5 shows the self-evaluation
assessment in which most subjects felt no change
in the number of acne lesions either before or
after the study.

Figure 2. Study Flow Chart

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Table 2. Severity of Acne According to Global Acne Grading System (GAGS) in Each Group Before and
After Treatment

Before After
Treatment Group
Mild Moderate Mild Moderate
Group 1 (once daily) 8 1 9 -
Group 2 (twice daily) 15 4 17 2
Group 3 (thrice daily) 10 - 9 1

Table 3. Frequency of Face Washing and Average Number of Acne Lesions Before and After the Treatment

Comedones Papules Pustules Nodules

Before After Before After Before After Before After
Group 1 (once daily) 18.2 13 6.4 4.7 0.7 0.1 0.5 0
Group 2 (twice daily) 21.3 20.1 5.7 6.7 0.7 0.3 0.3 0.2
Group 3 (thrice daily) 13.3 18.4 2.7 4.6 - 0.5 0.1 0

Table 4. Adverse Event in Each Treatment Group

Itchy Dryness Scaly No Complaint

Group 1 (once daily) 3 - - 6
Group 2 (twice daily) 2 4 4 10
Group 3 (thrice daily) 4 - - 6
Total 9 4 4 22

Table 5. Self-evaluation According to Change in the Number of Acne Lesion in Each Treatment Group

Improvement No Improvement Worsen

Group 1 (once daily) 3 5 1
Group 2 (twice daily) 8 9 2
Group 3 (thrice daily) 3 5 3
Total 14 19 6

Discussion
AV is a multifactorial disorder of the pilo-
sebaceous unit.16 It is a common skin disease
especially in adolescents and young adults.5 The
prevalence of acne among adolescent was
82,9%, 17 affecting over 90% of males and 80% of
females in all ethnic groups.18 In this study, all
selected subjects were males in order to avoid
menstrual cycle that might have influenced the
study result.
A survey of patient’s perception of AV showed
that they thought that acne was caused by poor
skin hygiene (29%), infection (18%), and dirt as
an aggravating factor (61%). Even among medical
students, 25% of them thought that poor facial
hygiene was an exacerbating factor.10 This study
was conducted to provide the right education to
the patients about the optimal face washing
frequency to reduce the prevalence of acne.
Methods of measuring the severity of AV include
simple grading based on clinical examination,
lesion counting, and those that require
complicated instruments such as photography,
fluorescent photography, polarized light
photography, video microscopy, and
measurement of sebum production. The first
person to use a scoring system for AV was
Carmen Thomas of Philadelphia, by using lesion
counting. In 1956, Pillsbury, Shelley and Kligman
published the earliest known grading system.
After that, Burke, Cunliffe and Gibson presented
the Leeds technique.19 Doshi et al15 introduced
Global Acne Grading System (GAGS).
In this study, inclusion criteria included mild and
moderate acne based on the GAGS scoring
system, in which the scoring system can be
assessed quickly and easily. The acne severity
was assessed by counting the number of each
lesion. The relationship between facial washing
and AV has not been clearly established. Acne
patients usually believe that lack of skin care and

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facial dirt aggravate acne, while dermatologists
used to believe that excessive facial washing
exacerbates acne and weakens the skin barrier
functions.20
A study by Kairavee et al.21 concluded that
washing face with soap is one of the triggers and
can be an aggravating factor of acne. In
comparison to our study, most subjects (93%) in
that study, the subjects washed their face only
with plain water regularly, because they had
experienced flares of their acne due to usage of
soaps and over time had become more
comfortable with plain water usage only. 21
Another literature also mentioned that washing
and scrubbing face vigorously could cause skin
irritation and worsen the acne. Washing the face
with a cleanser twice a day was recommended to
increase and improve therapy results.22
A study by Choi et al.20 clarified the effect of
frequency of face washing on AV. Twenty four
subjects were assigned to perform face washing
for once, twice, or four times a day for the duration
of six weeks. Significant improvement in both
open comedones and total non-inflammatory
lesions were observed in the group of twice face
washing in a day. Worsened condition was
observed in once face washing daily group. This
study gave recommendation to wash face twice
daily with a mild cleanser.20
In this study, group 1 and 2 experienced a
reduction in the average number of acne lesions,
while on group 3 had increased number of
lesions. The result of data analysis between face
washing frequency and number of lesions gave
significant result in group 1 and only on reduction
of comedones with p value <0.05. In addition,
most subjects did not experience the side effects
that usually arise as a result of washing the face
(redness/erythema, scaly, dry, stinging, hot, or
itchy). The result on self-evaluation gave out that
most subjects felt no improvement in acne
lesions.
Limitations of this study included that there were
no evaluations conducted between week 0 until
week 8 that may cause subjects’ non-adherence,
and also objective measurement such as
measuring the soap amount before and after the
study, and provision of checklist form to ensure
subjects’ compliance. These factors may affect
the number of drop out subjects in this study.
J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40.
Conclusion
There were significant results found on group 1
(face washing for once daily) and only supported
by reduction of comedones. Most subjects had no
complaints and in the self-evaluation assessment,
most subjects felt no change in the number of
acne lesions before and after the study. In
accordance to the results of this study, we
recommend to wash the face once daily for acne
patients with comedones lesion.
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